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New Antibiotic Premedication Guidelines in Dentistry

Recommendations for Those With Heart Conditions and Joint Replacements

A Consultation with Dr. Richard Andre Francoz & Dr. Kevin Louie

Dear Doctor,
I have congenital heart disease, and recently had a hip replacement. Do I need to take antibiotics before dental treatment?

Antibiotic premedication in dentistry.

Dear Cody,
Let’s start by reviewing what is at issue. Simply put, dental treatment can introduce bacteria from the mouth into the bloodstream, a condition known as bacteremia, which also occurs during natural processes like eating and even tooth brushing. In a small number of individuals, bacteremia may pose a health risk to those with:

  • Specific heart conditions that may predispose one to infective endocarditis (IE) — a serious and life-threatening infection of the heart lining and/or heart valves;
  • Total joint replacements that may predispose one to developing blood-borne infections at the site of the prosthetic (false) joint.

The recommendations for both conditions have been updated recently, so your question is very timely.

Congenital And Other Heart Conditions

The old recommendations called for individuals with nearly every type of congenital heart defect (“con” – together with; “genitus” – birth) to receive antibiotics one hour before dental procedures or oral surgery. Currently, the American Heart Association (AHA) recommends antibiotics before dental procedures only for patients with the highest risk of IE, who are those with:

  • An artificial heart valve or who have had a heart valve repaired with artificial material.
  • A history of endocarditis.
  • A heart transplant with abnormal heart valve function.
  • Certain congenital heart defects including:
    • Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal) that has not been fully repaired, including children who have had surgical shunts and conduits.
    • A congenital heart defect that’s been completely repaired with artificial material or a device for the first six months after the repair procedure.
    • Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic device.

Total Joint Replacement

In 2013, the American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS) released the first joint evidence-based guidelines on the prevention of orthopedic implant infection for patients undergoing dental procedures. They found no direct evidence that dental procedures cause orthopedic implant infections. Antibiotics are no longer recommended for everyone with artificial joints.

Ask your doctor (cardiologist or orthopedic surgeon accordingly) for his or her consideration and guidelines on whether you require antibiotic premedication for dental treatment — each person’s situation can be different.

As a result, healthcare providers may rely more on personal medical history to determine when antibiotics are appropriate before dental work for someone with orthopedic implants, which includes your hip-joint replacement.

But there are also other considerations to be taken into account. Antibiotic premedication might be useful for individuals who also have compromised immune (resistance) systems due to illnesses like diabetes, rheumatoid arthritis, cancer, chemotherapy, or chronic steroid use — all of which may increase the risk of orthopedic implant/joint infection.

Share Information With Your Healthcare Team

Tell your dentist if you have a heart condition of any kind, or have had a prosthetic (false) joint replacement. Also, ask your doctor (cardiologist or orthopedic surgeon accordingly) for his or her consideration and guidelines on whether you require antibiotic premedication for dental treatment — each person’s situation can be different. Please do not attempt to decide this important medical matter on your own or withhold any information about your health history, past or present, current medications, or history of allergy. Your dentist and your physician/s will work in concert to determine whether or not you need to premedicate with antibiotics prior to dental treatment.